{"id":15515,"date":"2023-05-31T19:54:31","date_gmt":"2023-05-31T16:24:31","guid":{"rendered":"https:\/\/avadaroon.com\/wood\/%d9%87%db%95%d8%b1%d8%b2%db%95%da%a9%d8%a7%d8%b1%d8%a7%d9%86\/"},"modified":"2023-09-03T18:08:37","modified_gmt":"2023-09-03T14:38:37","slug":"%d9%87%db%95%d8%b1%d8%b2%db%95%da%a9%d8%a7%d8%b1%d8%a7%d9%86","status":"publish","type":"page","link":"https:\/\/avadaroon.com\/ku\/%d9%87%db%95%d8%b1%d8%b2%db%95%da%a9%d8%a7%d8%b1%d8%a7%d9%86\/","title":{"rendered":"\u0647\u06d5\u0631\u0632\u06d5\u06a9\u0627\u0631\u0627\u0646"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"15515\" class=\"elementor elementor-15515 elementor-8821\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"wd-negative-gap elementor-section elementor-top-section elementor-element elementor-element-599b4c0 wd-section-stretch elementor-reverse-tablet elementor-reverse-mobile elementor-section-boxed elementor-section-height-default 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\/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-0259e08\" data-id=\"0259e08\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4e432fe elementor-widget elementor-widget-wp-widget-gform_widget\" data-id=\"4e432fe\" data-element_type=\"widget\" data-widget_type=\"wp-widget-gform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h5>\u0647\u06d5\u0631\u0632\u06d5\u06a9\u0627\u0631\u0627\u0646<\/h5><link rel='stylesheet' id='gform_basic-css' href='https:\/\/avadaroon.com\/wp-content\/plugins\/gravityforms\/assets\/css\/dist\/basic.min.css?ver=2.7.4' media='all' \/>\n<link rel='stylesheet' id='gform_theme_components-css' 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gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_6' ><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/ku\/wp-json\/wp\/v2\/pages\/15515#gf_6' data-formid='6' >\n        <div id='gf_progressbar_wrapper_6' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>10<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_10' style='width:10%;'><span>10%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_6_1' class='gform_page ' data-js='page-field-id-75' >\n                                    <div class='gform_page_fields'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_6_7\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_7\"><legend class='gfield_label gform-field-label'  >\u0646\u0627\u0633\u0646\u0627\u0645\u06d5\u06cc \u0695\u06d5\u06af\u06d5\u0632\u06cc\u062a \u0686\u06cc\u06cc\u06d5\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_7'>\n\t\t\t<div class='gchoice gchoice_6_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='\u0626\u0627\u0641\u0631\u06d5\u062a'  id='choice_6_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_7_0' id='label_6_7_0' class='gform-field-label gform-field-label--type-inline'>\u0626\u0627\u0641\u0631\u06d5\u062a<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='\u067e\u06cc\u0627\u0648'  id='choice_6_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_7_1' id='label_6_7_1' class='gform-field-label gform-field-label--type-inline'>\u067e\u06cc\u0627\u0648<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='gf_other_choice'  id='choice_6_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_7_2' id='label_6_7_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_6_7_other' class='gchoice_other_control' name='input_7_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_12\"  class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_12\"><label class='gfield_label gform-field-label' for='input_6_12' >\u062a\u06d5\u0645\u06d5\u0646\u062a \u0686\u06d5\u0646\u062f \u0633\u0627\u06b5\u06d5?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_6_12' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><option value='32' >32<\/option><option value='33' >33<\/option><option value='34' >34<\/option><option value='35' >35<\/option><option value='36' >36<\/option><option value='37' >37<\/option><option value='38' >38<\/option><option value='39' >39<\/option><option value='40' >40<\/option><option value='41' >41<\/option><option value='42' >42<\/option><option value='43' >43<\/option><option value='44' >44<\/option><option value='45' >45<\/option><option value='46' >46<\/option><option value='47' >47<\/option><option value='48' >48<\/option><option value='49' >49<\/option><option value='50' >50<\/option><option value='51' >51<\/option><option value='52' >52<\/option><option value='53' >53<\/option><option value='54' >54<\/option><option value='55' >55<\/option><option value='56' >56<\/option><option value='57' >57<\/option><option value='58' >58<\/option><option value='59' >59<\/option><option value='60' >60<\/option><option value='61' >61<\/option><option value='62' >62<\/option><option value='63' >63<\/option><option value='64' >64<\/option><option value='65' >65<\/option><option value='66' >66<\/option><option value='67' >67<\/option><option value='68' >68<\/option><option value='69' >69<\/option><option value='70' >70<\/option><option value='71' >71<\/option><option value='72' >72<\/option><option value='73' >73<\/option><option value='74' >74<\/option><option value='75' >75<\/option><option value='76' >76<\/option><option value='77' >77<\/option><option value='78' >78<\/option><option value='79' >79<\/option><option value='80' >80<\/option><option value='81' >81<\/option><option value='82' >82<\/option><option value='83' >83<\/option><option value='84' >84<\/option><option value='85' >85<\/option><option value='86' >86<\/option><option value='87' >87<\/option><option value='88' >88<\/option><option value='89' >89<\/option><option value='90' >90<\/option><option value='91' >91<\/option><option value='92' >92<\/option><option value='93' >93<\/option><option value='94' >94<\/option><option value='95' >95<\/option><option value='96' >96<\/option><option value='97' >97<\/option><option value='98' >98<\/option><option value='99' >99<\/option><\/select><\/div><\/div><fieldset id=\"field_6_8\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_8\"><legend class='gfield_label gform-field-label'  >\u062f\u06c6\u062e\u06cc \u067e\u06d5\u06cc\u0648\u06d5\u0646\u062f\u06cc\u062f\u0627\u0631\u06cc\u062a \u0686\u06cc\u06d5\u061f<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_8'>\n\t\t\t<div class='gchoice gchoice_6_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='\u062a\u0627\u06a9'  id='choice_6_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_8_0' id='label_6_8_0' class='gform-field-label gform-field-label--type-inline'>\u062a\u0627\u06a9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='\u0644\u06d5 \u067e\u06d5\u06cc\u0648\u06d5\u0646\u062f\u06cc\u062f\u0627'  id='choice_6_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_8_1' id='label_6_8_1' class='gform-field-label gform-field-label--type-inline'>\u0644\u06d5 \u067e\u06d5\u06cc\u0648\u06d5\u0646\u062f\u06cc\u062f\u0627<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='\u0647\u0627\u0648\u0633\u06d5\u0631\u06af\u06cc\u0631\u06cc \u06a9\u0631\u062f\u0648\u0648\u06d5'  id='choice_6_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_8_2' id='label_6_8_2' class='gform-field-label gform-field-label--type-inline'>\u0647\u0627\u0648\u0633\u06d5\u0631\u06af\u06cc\u0631\u06cc \u06a9\u0631\u062f\u0648\u0648\u06d5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='\u062c\u06cc\u0627\u0628\u0648\u0648\u06d5\u062a\u06d5\u0648\u06d5'  id='choice_6_8_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_8_3' id='label_6_8_3' class='gform-field-label gform-field-label--type-inline'>\u062c\u06cc\u0627\u0628\u0648\u0648\u06d5\u062a\u06d5\u0648\u06d5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_8_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='\u0628\u06ce\u0648\u06d5\u0698\u0646'  id='choice_6_8_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_8_4' id='label_6_8_4' class='gform-field-label gform-field-label--type-inline'>\u0628\u06ce\u0648\u06d5\u0698\u0646<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_8_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='gf_other_choice'  id='choice_6_8_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_8_5' id='label_6_8_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_6_8_other' class='gchoice_other_control' name='input_8_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_14\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_14\"><legend class='gfield_label gform-field-label'  >\u0686\u06c6\u0646 \u062f\u06d5\u0646\u0627\u0633\u06cc\u062a\u06d5\u0648\u06d5\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_14'>\n\t\t\t<div class='gchoice gchoice_6_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u0695\u0627\u0633\u062a\u06d5\u0648\u062e\u06c6'  id='choice_6_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_14_0' id='label_6_14_0' class='gform-field-label gform-field-label--type-inline'>\u0695\u0627\u0633\u062a\u06d5\u0648\u062e\u06c6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u0647\u0627\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632'  id='choice_6_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_14_1' id='label_6_14_1' class='gform-field-label gform-field-label--type-inline'>\u0647\u0627\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u0698\u0646\u06ce\u06a9\u06cc \u0647\u0627\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632'  id='choice_6_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_14_2' id='label_6_14_2' class='gform-field-label gform-field-label--type-inline'>\u0698\u0646\u06ce\u06a9\u06cc \u0647\u0627\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_14_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u062f\u0648\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632 \u0648\/\u06cc\u0627\u0646 \u067e\u0627\u0646\u0633\u06ce\u06a9\u0633\u0648\u0627\u0644'  id='choice_6_14_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_14_3' id='label_6_14_3' class='gform-field-label gform-field-label--type-inline'>\u062f\u0648\u0648\u0695\u06d5\u06af\u06d5\u0632\u0628\u0627\u0632 \u0648\/\u06cc\u0627\u0646 \u067e\u0627\u0646\u0633\u06ce\u06a9\u0633\u0648\u0627\u0644<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_14_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a'  id='choice_6_14_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_14_4' id='label_6_14_4' class='gform-field-label gform-field-label--type-inline'>\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_14_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='gf_other_choice'  id='choice_6_14_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_14_5' id='label_6_14_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_6_14_other' class='gchoice_other_control' name='input_14_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_23\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_23\"><legend class='gfield_label gform-field-label'  >\u0626\u0627\u06cc\u0627 \u062e\u06c6\u062a \u0628\u06d5 \u0626\u0627\u06cc\u0646\u06cc \u062f\u06d5\u0632\u0627\u0646\u06cc\u062a\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_23'>\n\t\t\t<div class='gchoice gchoice_6_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='\u0628\u06d5\u0644\u06ce'  id='choice_6_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_0' id='label_6_23_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5\u0644\u06ce<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='\u0646\u06d5\u062e\u06ce\u0631'  id='choice_6_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_1' id='label_6_23_1' class='gform-field-label gform-field-label--type-inline'>\u0646\u06d5\u062e\u06ce\u0631<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a'  id='choice_6_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_2' id='label_6_23_2' class='gform-field-label gform-field-label--type-inline'>\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_22\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_22\"><legend class='gfield_label gform-field-label'  >\u0626\u0627\u06cc\u0627 \u062e\u06c6\u062a \u0628\u06d5 \u0695\u06c6\u062d\u06cc \u062f\u06d5\u0632\u0627\u0646\u06cc\u062a\u061f<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_22'>\n\t\t\t<div class='gchoice gchoice_6_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='\u0628\u06d5\u0644\u06ce'  id='choice_6_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_22_0' id='label_6_22_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5\u0644\u06ce<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='\u0646\u06d5\u062e\u06ce\u0631'  id='choice_6_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_22_1' id='label_6_22_1' class='gform-field-label gform-field-label--type-inline'>\u0646\u06d5\u062e\u06ce\u0631<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a'  id='choice_6_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_22_2' id='label_6_22_2' class='gform-field-label gform-field-label--type-inline'>\u067e\u06ce\u062a \u0628\u0627\u0634\u06d5 \u0646\u06d5\u06b5\u06ce\u06cc\u062a<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_62' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_6_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_21\"><legend class='gfield_label gform-field-label'  >\u067e\u06ce\u0634\u062a\u0631 \u0644\u06d5 \u0686\u0627\u0631\u06d5\u0633\u06d5\u0631\u06a9\u0631\u062f\u0646\u062f\u0627 \u0628\u0648\u0648\u06cc\u062a\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_21'>\n\t\t\t<div class='gchoice gchoice_6_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='\u0628\u06d5\u0644\u06ce'  id='choice_6_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_21_0' id='label_6_21_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5\u0644\u06ce<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='\u0646\u06d5\u062e\u06ce\u0631'  id='choice_6_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_21_1' id='label_6_21_1' class='gform-field-label gform-field-label--type-inline'>\u0646\u06d5\u062e\u06ce\u0631<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_24\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_24\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0686\u06cc \u0648\u0627\u06cc \u0644\u06ce\u06a9\u0631\u062f\u06cc\u062a \u0626\u06d5\u0645\u0695\u06c6 \u0628\u06cc\u0631 \u0644\u06d5 \u0686\u0627\u0631\u06d5\u0633\u06d5\u0631\u06a9\u0631\u062f\u0646 \u0628\u06a9\u06d5\u06cc\u062a\u06d5\u0648\u06d5\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_24'><div class='gchoice gchoice_6_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='\u0647\u06d5\u0633\u062a\u0645 \u0628\u06d5 \u062e\u06d5\u0645\u06c6\u06a9\u06cc \u06a9\u0631\u062f\u0648\u0648\u06d5'  id='choice_6_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_1' id='label_6_24_1' class='gform-field-label gform-field-label--type-inline'>\u0647\u06d5\u0633\u062a\u0645 \u0628\u06d5 \u062e\u06d5\u0645\u06c6\u06a9\u06cc \u06a9\u0631\u062f\u0648\u0648\u06d5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='\u0647\u06d5\u0633\u062a \u0628\u06d5 \u062f\u06b5\u06d5\u0695\u0627\u0648\u06a9\u06ce\u06cc \u062f\u06b5\u06d5\u0695\u0627\u0648\u06a9\u06ce \u06cc\u0627\u0646 \u0633\u06d5\u0631\u06a9\u0648\u062a\u06a9\u0631\u062f\u0646 \u062f\u06d5\u06a9\u06d5\u0645'  id='choice_6_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_2' id='label_6_24_2' class='gform-field-label gform-field-label--type-inline'>\u0647\u06d5\u0633\u062a \u0628\u06d5 \u062f\u06b5\u06d5\u0695\u0627\u0648\u06a9\u06ce\u06cc \u062f\u06b5\u06d5\u0695\u0627\u0648\u06a9\u06ce \u06cc\u0627\u0646 \u0633\u06d5\u0631\u06a9\u0648\u062a\u06a9\u0631\u062f\u0646 \u062f\u06d5\u06a9\u06d5\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='\u0628\u0627\u0631\u06cc \u062f\u06d5\u0631\u0648\u0648\u0646\u06cc\u0645 \u062f\u06d5\u0633\u062a\u0648\u06d5\u0631\u062f\u0627\u0646 \u062f\u06d5\u06a9\u0627\u062a \u0644\u06d5 \u0626\u06d5\u062f\u0627\u06cc \u06a9\u0627\u0631\u06d5\u06a9\u06d5\u0645\/\u0642\u0648\u062a\u0627\u0628\u062e\u0627\u0646\u06d5\u06a9\u06d5\u0645'  id='choice_6_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_3' id='label_6_24_3' class='gform-field-label gform-field-label--type-inline'>\u0628\u0627\u0631\u06cc \u062f\u06d5\u0631\u0648\u0648\u0646\u06cc\u0645 \u062f\u06d5\u0633\u062a\u0648\u06d5\u0631\u062f\u0627\u0646 \u062f\u06d5\u06a9\u0627\u062a \u0644\u06d5 \u0626\u06d5\u062f\u0627\u06cc \u06a9\u0627\u0631\u06d5\u06a9\u06d5\u0645\/\u0642\u0648\u062a\u0627\u0628\u062e\u0627\u0646\u06d5\u06a9\u06d5\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='\u0645\u0646 \u06a9\u06ce\u0634\u06d5\u0645 \u0644\u06d5\u06af\u06d5\u06b5 \u062f\u0631\u0648\u0633\u062a\u06a9\u0631\u062f\u0646 \u06cc\u0627\u0646 \u067e\u0627\u0631\u0627\u0633\u062a\u0646\u06cc \u067e\u06d5\u06cc\u0648\u06d5\u0646\u062f\u06cc\u06cc\u06d5\u06a9\u0627\u0646 \u0647\u06d5\u06cc\u06d5'  id='choice_6_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_4' id='label_6_24_4' class='gform-field-label gform-field-label--type-inline'>\u0645\u0646 \u06a9\u06ce\u0634\u06d5\u0645 \u0644\u06d5\u06af\u06d5\u06b5 \u062f\u0631\u0648\u0633\u062a\u06a9\u0631\u062f\u0646 \u06cc\u0627\u0646 \u067e\u0627\u0631\u0627\u0633\u062a\u0646\u06cc \u067e\u06d5\u06cc\u0648\u06d5\u0646\u062f\u06cc\u06cc\u06d5\u06a9\u0627\u0646 \u0647\u06d5\u06cc\u06d5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='\u0646\u0627\u062a\u0648\u0627\u0646\u0645 \u0626\u0627\u0645\u0627\u0646\u062c \u0648 \u0645\u0627\u0646\u0627 \u0644\u06d5 \u0698\u06cc\u0627\u0646\u0645\u062f\u0627 \u0628\u062f\u06c6\u0632\u0645\u06d5\u0648\u06d5'  id='choice_6_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_5' id='label_6_24_5' class='gform-field-label gform-field-label--type-inline'>\u0646\u0627\u062a\u0648\u0627\u0646\u0645 \u0626\u0627\u0645\u0627\u0646\u062c \u0648 \u0645\u0627\u0646\u0627 \u0644\u06d5 \u0698\u06cc\u0627\u0646\u0645\u062f\u0627 \u0628\u062f\u06c6\u0632\u0645\u06d5\u0648\u06d5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='\u0645\u0646 \u062e\u06d5\u0645\u0628\u0627\u0631\u0645'  id='choice_6_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_6' id='label_6_24_6' class='gform-field-label gform-field-label--type-inline'>\u0645\u0646 \u062e\u06d5\u0645\u0628\u0627\u0631\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='\u0645\u0646 \u062a\u0648\u0648\u0634\u06cc \u0632\u06d5\u0628\u0631 \u0648 \u0632\u06d5\u0646\u06af \u0628\u0648\u0648\u0645'  id='choice_6_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_7' id='label_6_24_7' class='gform-field-label gform-field-label--type-inline'>\u0645\u0646 \u062a\u0648\u0648\u0634\u06cc \u0632\u06d5\u0628\u0631 \u0648 \u0632\u06d5\u0646\u06af \u0628\u0648\u0648\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='\u067e\u06ce\u0648\u06cc\u0633\u062a\u06d5 \u0644\u06d5 \u0695\u06ce\u06af\u06d5\u06cc \u062a\u06d5\u062d\u06d5\u062f\u0627\u06cc\u06d5\u06a9\u06cc \u062f\u06cc\u0627\u0631\u06cc\u06a9\u0631\u0627\u0648\u06d5\u0648\u06d5 \u0642\u0633\u06d5 \u0628\u06a9\u06d5\u0645'  id='choice_6_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_8' id='label_6_24_8' class='gform-field-label gform-field-label--type-inline'>\u067e\u06ce\u0648\u06cc\u0633\u062a\u06d5 \u0644\u06d5 \u0695\u06ce\u06af\u06d5\u06cc \u062a\u06d5\u062d\u06d5\u062f\u0627\u06cc\u06d5\u06a9\u06cc \u062f\u06cc\u0627\u0631\u06cc\u06a9\u0631\u0627\u0648\u06d5\u0648\u06d5 \u0642\u0633\u06d5 \u0628\u06a9\u06d5\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='\u0645\u0646 \u062f\u06d5\u0645\u06d5\u0648\u06ce\u062a \u0645\u062a\u0645\u0627\u0646\u06d5 \u0628\u06d5\u062e\u06c6\u0645 \u0628\u06d5\u062f\u06d5\u0633\u062a \u0628\u0647\u06ce\u0646\u0645'  id='choice_6_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_9' id='label_6_24_9' class='gform-field-label gform-field-label--type-inline'>\u0645\u0646 \u062f\u06d5\u0645\u06d5\u0648\u06ce\u062a \u0645\u062a\u0645\u0627\u0646\u06d5 \u0628\u06d5\u062e\u06c6\u0645 \u0628\u06d5\u062f\u06d5\u0633\u062a \u0628\u0647\u06ce\u0646\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='\u0645\u0646 \u062f\u06d5\u0645\u06d5\u0648\u06ce\u062a \u062e\u06c6\u0645 \u0628\u0627\u0634\u062a\u0631 \u0628\u06a9\u06d5\u0645 \u0628\u06d5\u06b5\u0627\u0645 \u0646\u0627\u0632\u0627\u0646\u0645 \u0644\u06d5 \u06a9\u0648\u06ce\u0648\u06d5 \u062f\u06d5\u0633\u062a \u067e\u06ce \u0628\u06a9\u06d5\u0645'  id='choice_6_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_11' id='label_6_24_11' class='gform-field-label gform-field-label--type-inline'>\u0645\u0646 \u062f\u06d5\u0645\u06d5\u0648\u06ce\u062a \u062e\u06c6\u0645 \u0628\u0627\u0634\u062a\u0631 \u0628\u06a9\u06d5\u0645 \u0628\u06d5\u06b5\u0627\u0645 \u0646\u0627\u0632\u0627\u0646\u0645 \u0644\u06d5 \u06a9\u0648\u06ce\u0648\u06d5 \u062f\u06d5\u0633\u062a \u067e\u06ce \u0628\u06a9\u06d5\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='\u067e\u06ce\u0634\u0646\u06cc\u0627\u0631 \u06a9\u0631\u0627\u0648\u06d5 \u0628\u06c6 \u0645\u0646 (\u0647\u0627\u0648\u0695\u06ce\u060c \u062e\u06ce\u0632\u0627\u0646\u060c \u067e\u0632\u06cc\u0634\u06a9)'  id='choice_6_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_12' id='label_6_24_12' class='gform-field-label gform-field-label--type-inline'>\u067e\u06ce\u0634\u0646\u06cc\u0627\u0631 \u06a9\u0631\u0627\u0648\u06d5 \u0628\u06c6 \u0645\u0646 (\u0647\u0627\u0648\u0695\u06ce\u060c \u062e\u06ce\u0632\u0627\u0646\u060c \u067e\u0632\u06cc\u0634\u06a9)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='\u062a\u06d5\u0646\u0647\u0627 \u06af\u06d5\u0695\u0627\u0646'  id='choice_6_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_24_13' id='label_6_24_13' class='gform-field-label gform-field-label--type-inline'>\u062a\u06d5\u0646\u0647\u0627 \u06af\u06d5\u0695\u0627\u0646<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_69' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"1\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"1\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_69' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_6_25\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_25\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0686\u0627\u0648\u06d5\u0695\u0648\u0627\u0646\u06cc\u06cc\u06d5\u06a9\u0627\u0646\u062a \u0644\u06d5 \u0686\u0627\u0631\u06d5\u0633\u06d5\u0631\u06a9\u06d5\u0631\u06d5\u06a9\u06d5\u062a \u0686\u06cc\u0646\u061f \u0686\u0627\u0631\u06d5\u0633\u06d5\u0631\u06a9\u06d5\u0631\u06ce\u06a9 \u06a9\u06d5 ...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_25'><div class='gchoice gchoice_6_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='\u06af\u0648\u06ce \u062f\u06d5\u06af\u0631\u06ce\u062a'  id='choice_6_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_25_1' id='label_6_25_1' class='gform-field-label gform-field-label--type-inline'>\u06af\u0648\u06ce \u062f\u06d5\u06af\u0631\u06ce\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='\u0628\u06d5\u062f\u0648\u0627\u062f\u0627\u0686\u0648\u0648\u0646 \u0628\u06c6 \u0695\u0627\u0628\u0631\u062f\u0648\u0648\u0645 \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_25_2' id='label_6_25_2' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5\u062f\u0648\u0627\u062f\u0627\u0686\u0648\u0648\u0646 \u0628\u06c6 \u0695\u0627\u0628\u0631\u062f\u0648\u0648\u0645 \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='\u0641\u06ce\u0631\u06cc \u06a9\u0627\u0631\u0627\u0645\u06d5\u06cc\u06cc \u0646\u0648\u06ce\u0645 \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_25_3' id='label_6_25_3' class='gform-field-label gform-field-label--type-inline'>\u0641\u06ce\u0631\u06cc \u06a9\u0627\u0631\u0627\u0645\u06d5\u06cc\u06cc \u0646\u0648\u06ce\u0645 \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='\u062a\u06d5\u062d\u06d5\u062f\u0627\u06cc \u0628\u06cc\u0631\u0648\u0628\u0627\u0648\u06d5\u0695\u06d5\u06a9\u0627\u0646\u0645 \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_25_4' id='label_6_25_4' class='gform-field-label gform-field-label--type-inline'>\u062a\u06d5\u062d\u06d5\u062f\u0627\u06cc \u0628\u06cc\u0631\u0648\u0628\u0627\u0648\u06d5\u0695\u06d5\u06a9\u0627\u0646\u0645 \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='\u0626\u06d5\u0631\u06a9\u06cc \u0645\u0627\u06b5\u06d5\u0648\u06d5\u0645 \u0628\u06c6 \u062f\u06cc\u0627\u0631\u06cc \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_25_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_25_5' id='label_6_25_5' class='gform-field-label gform-field-label--type-inline'>\u0626\u06d5\u0631\u06a9\u06cc \u0645\u0627\u06b5\u06d5\u0648\u06d5\u0645 \u0628\u06c6 \u062f\u06cc\u0627\u0631\u06cc \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_25_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.6' type='checkbox'  value='\u0695\u06ce\u0646\u0645\u0627\u06cc\u06cc\u0645 \u062f\u06d5\u06a9\u0627\u062a \u0628\u06c6 \u062f\u0627\u0646\u0627\u0646\u06cc \u0626\u0627\u0645\u0627\u0646\u062c'  id='choice_6_25_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_25_6' id='label_6_25_6' class='gform-field-label gform-field-label--type-inline'>\u0695\u06ce\u0646\u0645\u0627\u06cc\u06cc\u0645 \u062f\u06d5\u06a9\u0627\u062a \u0628\u06c6 \u062f\u0627\u0646\u0627\u0646\u06cc \u0626\u0627\u0645\u0627\u0646\u062c<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_25_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.7' type='checkbox'  value='\u0628\u06d5 \u0634\u06ce\u0648\u06d5\u06cc\u06d5\u06a9\u06cc \u0686\u0627\u0644\u0627\u06a9\u0627\u0646\u06d5 \u0644\u06d5\u06af\u06d5\u06b5\u0645\u062f\u0627 \u0686\u06ce\u06a9 \u0626\u06cc\u0646 \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_25_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_25_7' id='label_6_25_7' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5 \u0634\u06ce\u0648\u06d5\u06cc\u06d5\u06a9\u06cc \u0686\u0627\u0644\u0627\u06a9\u0627\u0646\u06d5 \u0644\u06d5\u06af\u06d5\u06b5\u0645\u062f\u0627 \u0686\u06ce\u06a9 \u0626\u06cc\u0646 \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_25_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.8' type='checkbox'  value='\u0646\u0627\u0632\u0627\u0646\u0645'  id='choice_6_25_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_25_8' id='label_6_25_8' class='gform-field-label gform-field-label--type-inline'>\u0646\u0627\u0632\u0627\u0646\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_20\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_20\"><legend class='gfield_label gform-field-label'  >\u062a\u06d5\u0646\u062f\u0631\u0648\u0633\u062a\u06cc \u062c\u06d5\u0633\u062a\u06d5\u06cc\u06cc \u0626\u06ce\u0633\u062a\u0627\u062a \u0686\u06c6\u0646 \u0647\u06d5\u06b5\u062f\u06d5\u0633\u06d5\u0646\u06af\u06ce\u0646\u06cc\u062a\u061f<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_20'>\n\t\t\t<div class='gchoice gchoice_6_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='\u0628\u0627\u0634'  id='choice_6_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_20_0' id='label_6_20_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u0627\u0634<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='\u062f\u0627\u062f\u067e\u06d5\u0631\u0648\u06d5\u0631\u0627\u0646\u06d5'  id='choice_6_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_20_1' id='label_6_20_1' class='gform-field-label gform-field-label--type-inline'>\u062f\u0627\u062f\u067e\u06d5\u0631\u0648\u06d5\u0631\u0627\u0646\u06d5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='\u0647\u06d5\u0698\u0627\u0631'  id='choice_6_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_20_2' id='label_6_20_2' class='gform-field-label gform-field-label--type-inline'>\u0647\u06d5\u0698\u0627\u0631<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_75\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_75\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >\u0686\u0627\u0648\u06d5\u0695\u0648\u0627\u0646\u06cc\u06cc\u06d5\u06a9\u0627\u0646\u062a \u0644\u06d5 \u0686\u0627\u0631\u06d5\u0633\u06d5\u0631\u06a9\u06d5\u0631\u06d5\u06a9\u06d5\u062a \u0686\u06cc\u0646\u061f \u0686\u0627\u0631\u06d5\u0633\u06d5\u0631\u06a9\u06d5\u0631\u06ce\u06a9 \u06a9\u06d5 ...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_75'><div class='gchoice gchoice_6_75_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.1' type='checkbox'  value='\u06af\u0648\u06ce \u062f\u06d5\u06af\u0631\u06ce\u062a'  id='choice_6_75_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_1' id='label_6_75_1' class='gform-field-label gform-field-label--type-inline'>\u06af\u0648\u06ce \u062f\u06d5\u06af\u0631\u06ce\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_75_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.2' type='checkbox'  value='\u0628\u06d5\u062f\u0648\u0627\u062f\u0627\u0686\u0648\u0648\u0646 \u0628\u06c6 \u0695\u0627\u0628\u0631\u062f\u0648\u0648\u0645 \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_75_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_2' id='label_6_75_2' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5\u062f\u0648\u0627\u062f\u0627\u0686\u0648\u0648\u0646 \u0628\u06c6 \u0695\u0627\u0628\u0631\u062f\u0648\u0648\u0645 \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_75_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.3' type='checkbox'  value='\u0641\u06ce\u0631\u06cc \u06a9\u0627\u0631\u0627\u0645\u06d5\u06cc\u06cc \u0646\u0648\u06ce\u0645 \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_75_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_3' id='label_6_75_3' class='gform-field-label gform-field-label--type-inline'>\u0641\u06ce\u0631\u06cc \u06a9\u0627\u0631\u0627\u0645\u06d5\u06cc\u06cc \u0646\u0648\u06ce\u0645 \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_75_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.4' type='checkbox'  value='\u062a\u06d5\u062d\u06d5\u062f\u0627\u06cc \u0628\u06cc\u0631\u0648\u0628\u0627\u0648\u06d5\u0695\u06d5\u06a9\u0627\u0646\u0645 \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_75_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_4' id='label_6_75_4' class='gform-field-label gform-field-label--type-inline'>\u062a\u06d5\u062d\u06d5\u062f\u0627\u06cc \u0628\u06cc\u0631\u0648\u0628\u0627\u0648\u06d5\u0695\u06d5\u06a9\u0627\u0646\u0645 \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_75_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.5' type='checkbox'  value='\u0626\u06d5\u0631\u06a9\u06cc \u0645\u0627\u06b5\u06d5\u0648\u06d5\u0645 \u0628\u06c6 \u062f\u06cc\u0627\u0631\u06cc \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_75_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_5' id='label_6_75_5' class='gform-field-label gform-field-label--type-inline'>\u0626\u06d5\u0631\u06a9\u06cc \u0645\u0627\u06b5\u06d5\u0648\u06d5\u0645 \u0628\u06c6 \u062f\u06cc\u0627\u0631\u06cc \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_75_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.6' type='checkbox'  value='\u0695\u06ce\u0646\u0645\u0627\u06cc\u06cc\u0645 \u062f\u06d5\u06a9\u0627\u062a \u0628\u06c6 \u062f\u0627\u0646\u0627\u0646\u06cc \u0626\u0627\u0645\u0627\u0646\u062c'  id='choice_6_75_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_6' id='label_6_75_6' class='gform-field-label gform-field-label--type-inline'>\u0695\u06ce\u0646\u0645\u0627\u06cc\u06cc\u0645 \u062f\u06d5\u06a9\u0627\u062a \u0628\u06c6 \u062f\u0627\u0646\u0627\u0646\u06cc \u0626\u0627\u0645\u0627\u0646\u062c<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_75_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.7' type='checkbox'  value='\u0628\u06d5 \u0634\u06ce\u0648\u06d5\u06cc\u06d5\u06a9\u06cc \u0686\u0627\u0644\u0627\u06a9\u0627\u0646\u06d5 \u0644\u06d5\u06af\u06d5\u06b5\u0645\u062f\u0627 \u0686\u06ce\u06a9 \u0626\u06cc\u0646 \u062f\u06d5\u06a9\u0627\u062a'  id='choice_6_75_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_7' id='label_6_75_7' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5 \u0634\u06ce\u0648\u06d5\u06cc\u06d5\u06a9\u06cc \u0686\u0627\u0644\u0627\u06a9\u0627\u0646\u06d5 \u0644\u06d5\u06af\u06d5\u06b5\u0645\u062f\u0627 \u0686\u06ce\u06a9 \u0626\u06cc\u0646 \u062f\u06d5\u06a9\u0627\u062a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_75_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.8' type='checkbox'  value='\u0646\u0627\u0632\u0627\u0646\u0645'  id='choice_6_75_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_8' id='label_6_75_8' class='gform-field-label gform-field-label--type-inline'>\u0646\u0627\u0632\u0627\u0646\u0645<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_19\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_19\"><legend class='gfield_label gform-field-label'  >\u0686\u06c6\u0646 \u0647\u06d5\u06b5\u0633\u06d5\u0646\u06af\u0627\u0646\u062f\u0646 \u0628\u06c6 \u062e\u0648\u0648\u06d5\u06a9\u0627\u0646\u06cc \u0626\u06ce\u0633\u062a\u0627\u06cc \u062e\u0648\u0627\u0631\u062f\u0646\u062a \u062f\u06d5\u06a9\u06d5\u06cc\u062a\u061f<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_19'>\n\t\t\t<div class='gchoice gchoice_6_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='\u0628\u0627\u0634'  id='choice_6_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_19_0' id='label_6_19_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u0627\u0634<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='\u062f\u0627\u062f\u067e\u06d5\u0631\u0648\u06d5\u0631\u0627\u0646\u06d5'  id='choice_6_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_19_1' id='label_6_19_1' class='gform-field-label gform-field-label--type-inline'>\u062f\u0627\u062f\u067e\u06d5\u0631\u0648\u06d5\u0631\u0627\u0646\u06d5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='\u0647\u06d5\u0698\u0627\u0631'  id='choice_6_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_19_2' id='label_6_19_2' class='gform-field-label gform-field-label--type-inline'>\u0647\u06d5\u0698\u0627\u0631<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_18\"><legend class='gfield_label gform-field-label'  >\u0626\u0627\u06cc\u0627 \u0644\u06d5 \u0626\u06ce\u0633\u062a\u0627\u062f\u0627 \u062a\u0648\u0648\u0634\u06cc \u062e\u06d5\u0645 \u0648 \u067e\u06d5\u0698\u0627\u0631\u06d5\u060c \u062e\u06d5\u0645\u060c \u06cc\u0627\u0646 \u062e\u06d5\u0645\u06c6\u06a9\u06cc\u06cc\u06d5\u06a9\u06cc \u0632\u06c6\u0631 \u062f\u06d5\u0628\u06cc\u062a\u061f<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_18'>\n\t\t\t<div class='gchoice gchoice_6_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='\u0628\u06d5\u06b5\u06ce'  id='choice_6_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_18_0' id='label_6_18_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5\u06b5\u06ce<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='\u0646\u06d5\u062e\u06ce\u0631'  id='choice_6_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_18_1' id='label_6_18_1' class='gform-field-label gform-field-label--type-inline'>\u0646\u06d5\u062e\u06ce\u0631<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_73' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_73' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"4\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"4\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_4' class='gform_page' data-js='page-field-id-73' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_6_27\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_27\">\u0644\u06d5 \u0645\u0627\u0648\u06d5\u06cc \u0662 \u0647\u06d5\u0641\u062a\u06d5\u06cc \u0695\u0627\u0628\u0631\u062f\u0648\u0648\u062f\u0627\u060c \u0686\u06d5\u0646\u062f \u062c\u0627\u0631 \u0628\u06ce\u0632\u0627\u0631 \u0628\u0648\u0648\u06cc\u062a \u0628\u06d5\u0647\u06c6\u06cc \u0647\u06d5\u0631\u06cc\u06d5\u06a9\u06ce\u06a9 \u0644\u06d5\u0645 \u06a9\u06ce\u0634\u0627\u0646\u06d5\u06cc \u062e\u0648\u0627\u0631\u06d5\u0648\u06d5:<\/div><fieldset id=\"field_6_16\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_16\"><legend class='gfield_label gform-field-label'  >\u062c\u0648\u06b5\u06d5 \u06cc\u0627\u0646 \u0642\u0633\u06d5\u06a9\u0631\u062f\u0646 \u0626\u06d5\u0648\u06d5\u0646\u062f\u06d5 \u0628\u06d5 \u0647\u06ce\u0648\u0627\u0634\u06cc \u06a9\u06d5 \u062e\u06d5\u06b5\u06a9\u06cc \u062a\u0631 \u062f\u06d5\u06cc\u0627\u0646\u062a\u0648\u0627\u0646\u06cc \u062a\u06ce\u0628\u06cc\u0646\u06cc \u0628\u06a9\u06d5\u0646\u061f \u06cc\u0627\u0646 \u067e\u06ce\u0686\u06d5\u0648\u0627\u0646\u06d5\u06a9\u06d5\u06cc - \u0626\u06d5\u0648\u06d5\u0646\u062f\u06d5 \u0686\u06d5\u0642\u0628\u06d5\u0633\u062a\u0648\u0648 \u06cc\u0627\u0646 \u0646\u0627\u0626\u0627\u0631\u0627\u0645 \u0628\u0648\u0648\u0646 \u06a9\u06d5 \u0632\u06c6\u0631 \u0632\u06cc\u0627\u062a\u0631 \u0644\u06d5 \u0626\u0627\u0633\u0627\u06cc\u06cc \u0628\u06d5\u062f\u06d5\u0648\u0631\u06cc \u062e\u06c6\u062a\u062f\u0627 \u062f\u06d5\u062c\u0648\u06b5\u06ce\u06cc\u062a.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_16'>\n\t\t\t<div class='gchoice gchoice_6_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u0628\u06d5 \u0647\u06cc\u0686 \u0634\u06ce\u0648\u06d5\u06cc\u06d5\u06a9'  id='choice_6_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_16_0' id='label_6_16_0' class='gform-field-label gform-field-label--type-inline'>\u0628\u06d5 \u0647\u06cc\u0686 \u0634\u06ce\u0648\u06d5\u06cc\u06d5\u06a9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u0686\u06d5\u0646\u062f \u0695\u06c6\u0698\u06ce\u06a9'  id='choice_6_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_16_1' id='label_6_16_1' class='gform-field-label gform-field-label--type-inline'>\u0686\u06d5\u0646\u062f \u0695\u06c6\u0698\u06ce\u06a9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u0632\u06cc\u0627\u062a\u0631 \u0644\u06d5 \u0646\u06cc\u0648\u06d5\u06cc \u0695\u06c6\u0698\u06d5\u06a9\u0627\u0646'  id='choice_6_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_16_2' id='label_6_16_2' class='gform-field-label gform-field-label--type-inline'>\u0632\u06cc\u0627\u062a\u0631 \u0644\u06d5 \u0646\u06cc\u0648\u06d5\u06cc \u0695\u06c6\u0698\u06d5\u06a9\u0627\u0646<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u0646\u0632\u06cc\u06a9\u06d5\u06cc \u0647\u06d5\u0645\u0648\u0648 \u0695\u06c6\u0698\u06ce\u06a9'  id='choice_6_16_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_16_3' id='label_6_16_3' class='gform-field-label gform-field-label--type-inline'>\u0646\u0632\u06cc\u06a9\u06d5\u06cc \u0647\u06d5\u0645\u0648\u0648 \u0695\u06c6\u0698\u06ce\u06a9<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_17\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_17\"><legend class='gfield_label gform-field-label'  >Little interest or pleasure in doing things.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_17'>\n\t\t\t<div class='gchoice gchoice_6_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Not at all'  id='choice_6_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_17_0' id='label_6_17_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Several days'  id='choice_6_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_17_1' id='label_6_17_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='More than half the days'  id='choice_6_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_17_2' id='label_6_17_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_17_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Nearly every day'  id='choice_6_17_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_17_3' id='label_6_17_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_29\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_29\"><legend class='gfield_label gform-field-label'  >Trouble falling asleep, staying asleep, or sleeping too much.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_29'>\n\t\t\t<div class='gchoice gchoice_6_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Not at all'  id='choice_6_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_0' id='label_6_29_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Several days'  id='choice_6_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_1' id='label_6_29_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='More than half the days'  id='choice_6_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_2' id='label_6_29_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_29_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Nearly every day'  id='choice_6_29_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_3' id='label_6_29_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_30\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_30\"><legend class='gfield_label gform-field-label'  >Feeling tired or having little energy.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_30'>\n\t\t\t<div class='gchoice gchoice_6_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Not at all'  id='choice_6_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_30_0' id='label_6_30_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Several days'  id='choice_6_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_30_1' id='label_6_30_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='More than half the days'  id='choice_6_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_30_2' id='label_6_30_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Nearly every day'  id='choice_6_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_30_3' id='label_6_30_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_28\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_28\"><legend class='gfield_label gform-field-label'  >Feeling down, depressed or hopeless.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_28'>\n\t\t\t<div class='gchoice gchoice_6_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Not at all'  id='choice_6_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_0' id='label_6_28_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Several days'  id='choice_6_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_1' id='label_6_28_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='More than half the days'  id='choice_6_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_2' id='label_6_28_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Nearly every day'  id='choice_6_28_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_3' id='label_6_28_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_70' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_70' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"5\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"5\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_5' class='gform_page' data-js='page-field-id-70' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_5' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_6_31\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_31\"><legend class='gfield_label gform-field-label'  >Poor appetite or overeating.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_31'>\n\t\t\t<div class='gchoice gchoice_6_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Not at all'  id='choice_6_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_31_0' id='label_6_31_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Several days'  id='choice_6_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_31_1' id='label_6_31_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='More than half the days'  id='choice_6_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_31_2' id='label_6_31_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Nearly every day'  id='choice_6_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_31_3' id='label_6_31_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_32\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_32\"><legend class='gfield_label gform-field-label'  >Feeling bad about yourself - or that you are a failure or have let yourself or your family down.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_32'>\n\t\t\t<div class='gchoice gchoice_6_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Not at all'  id='choice_6_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_32_0' id='label_6_32_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Several days'  id='choice_6_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_32_1' id='label_6_32_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='More than half the days'  id='choice_6_32_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_32_2' id='label_6_32_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_32_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Nearly every day'  id='choice_6_32_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_32_3' id='label_6_32_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_33\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_33\"><legend class='gfield_label gform-field-label'  >Trouble concentrating on things, such as reading the newspaper or watching television.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_33'>\n\t\t\t<div class='gchoice gchoice_6_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Not at all'  id='choice_6_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_33_0' id='label_6_33_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Several days'  id='choice_6_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_33_1' id='label_6_33_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_33_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='More than half the days'  id='choice_6_33_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_33_2' id='label_6_33_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_33_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Nearly every day'  id='choice_6_33_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_33_3' id='label_6_33_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_36\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_36\"><legend class='gfield_label gform-field-label'  >Thoughts that you would be better off dead or of hurting yourself in some way.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_36'>\n\t\t\t<div class='gchoice gchoice_6_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Not at all'  id='choice_6_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_0' id='label_6_36_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Several days'  id='choice_6_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_1' id='label_6_36_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='More than half the days'  id='choice_6_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_2' id='label_6_36_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_36_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Nearly every day'  id='choice_6_36_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_3' id='label_6_36_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_34\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_34\"><legend class='gfield_label gform-field-label'  >How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_34'>\n\t\t\t<div class='gchoice gchoice_6_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Not at all'  id='choice_6_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_34_0' id='label_6_34_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Several days'  id='choice_6_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_34_1' id='label_6_34_1' class='gform-field-label gform-field-label--type-inline'>Several days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='More than half the days'  id='choice_6_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_34_2' id='label_6_34_2' class='gform-field-label gform-field-label--type-inline'>More than half the days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Nearly every day'  id='choice_6_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_34_3' id='label_6_34_3' class='gform-field-label gform-field-label--type-inline'>Nearly every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_64' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"4\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"4\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_64' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"6\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"6\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_6' class='gform_page' data-js='page-field-id-64' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_6' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_6_37\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_37\">Please fill out this short questionnaire to provide some background information about you and the issues you'd like to deal with in therapy. It would help us match you with the most suitable therapist for you. Your answers will also give this therapist a good starting point in getting to know you.<\/div><fieldset id=\"field_6_38\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_38\"><legend class='gfield_label gform-field-label'  >Are you currently employed?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_38'>\n\t\t\t<div class='gchoice gchoice_6_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_6_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_38_0' id='label_6_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_6_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_38_1' id='label_6_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_39\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_39\"><legend class='gfield_label gform-field-label'  >Do you have any problems or worries about intimacy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_39'>\n\t\t\t<div class='gchoice gchoice_6_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_6_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_39_0' id='label_6_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_6_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_39_1' id='label_6_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_40\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_40\"><legend class='gfield_label gform-field-label'  >How often do you drink alcohol?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_40'>\n\t\t\t<div class='gchoice gchoice_6_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Never'  id='choice_6_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_40_0' id='label_6_40_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Infrequently'  id='choice_6_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_40_1' id='label_6_40_1' class='gform-field-label gform-field-label--type-inline'>Infrequently<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_40_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Monthly'  id='choice_6_40_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_40_2' id='label_6_40_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_40_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Weekly'  id='choice_6_40_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_40_3' id='label_6_40_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_40_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Daily'  id='choice_6_40_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_40_4' id='label_6_40_4' class='gform-field-label gform-field-label--type-inline'>Daily<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_41\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_41\"><legend class='gfield_label gform-field-label'  >When was the last time you thought about suicide?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_41'>\n\t\t\t<div class='gchoice gchoice_6_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Never'  id='choice_6_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_41_0' id='label_6_41_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Over a years ago'  id='choice_6_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_41_1' id='label_6_41_1' class='gform-field-label gform-field-label--type-inline'>Over a years ago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Over a month ago'  id='choice_6_41_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_41_2' id='label_6_41_2' class='gform-field-label gform-field-label--type-inline'>Over a month ago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_41_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Over a week ago'  id='choice_6_41_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_41_3' id='label_6_41_3' class='gform-field-label gform-field-label--type-inline'>Over a week ago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_41_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Every day'  id='choice_6_41_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_41_4' id='label_6_41_4' class='gform-field-label gform-field-label--type-inline'>Every day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_48\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_48\"><legend class='gfield_label gform-field-label'  >How do you prefer to communicate with your therapist?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_48'>\n\t\t\t<div class='gchoice gchoice_6_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Mostly via messaging'  id='choice_6_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_48_0' id='label_6_48_0' class='gform-field-label gform-field-label--type-inline'>Mostly via messaging<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Mostly via messaging'  id='choice_6_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_48_1' id='label_6_48_1' class='gform-field-label gform-field-label--type-inline'>Mostly via messaging<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Not sure yet (decide later)'  id='choice_6_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_48_2' id='label_6_48_2' class='gform-field-label gform-field-label--type-inline'>Not sure yet (decide later)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_42\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_42\"><legend class='gfield_label gform-field-label'  >Are you currently experiencing anxiety, panic attacks or have any phobias?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_42'>\n\t\t\t<div class='gchoice gchoice_6_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_6_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_42_0' id='label_6_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_6_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_42_1' id='label_6_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_67' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"5\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"5\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_67' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"7\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"7\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_7' class='gform_page' data-js='page-field-id-67' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_7' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_6_43\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_43\"><legend class='gfield_label gform-field-label'  >Are you currently taking any medication?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_43'>\n\t\t\t<div class='gchoice gchoice_6_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_6_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_43_0' id='label_6_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_6_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_43_1' id='label_6_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_44\"><legend class='gfield_label gform-field-label'  >Are you currently experiencing any chronic pain?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_44'>\n\t\t\t<div class='gchoice gchoice_6_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_6_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_44_0' id='label_6_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_6_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_44_1' id='label_6_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_46\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_46\"><legend class='gfield_label gform-field-label'  >How would you rate your current financial status?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_46'>\n\t\t\t<div class='gchoice gchoice_6_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Good'  id='choice_6_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_46_0' id='label_6_46_0' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Fair'  id='choice_6_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_46_1' id='label_6_46_1' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Poor'  id='choice_6_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_46_2' id='label_6_46_2' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_47\"><legend class='gfield_label gform-field-label'  >How would you rate your current sleeping habits?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_47'>\n\t\t\t<div class='gchoice gchoice_6_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Good'  id='choice_6_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_47_0' id='label_6_47_0' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Fair'  id='choice_6_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_47_1' id='label_6_47_1' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Poor'  id='choice_6_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_47_2' id='label_6_47_2' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_49\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_49\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Are there any specific preferences for your therapist?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_49'><div class='gchoice gchoice_6_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Male therapist'  id='choice_6_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_1' id='label_6_49_1' class='gform-field-label gform-field-label--type-inline'>Male therapist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Female therapist'  id='choice_6_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_2' id='label_6_49_2' class='gform-field-label gform-field-label--type-inline'>Female therapist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='Christian-based therapy'  id='choice_6_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_3' id='label_6_49_3' class='gform-field-label gform-field-label--type-inline'>Christian-based therapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Therapist from the LGBTQ+ community'  id='choice_6_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_4' id='label_6_49_4' class='gform-field-label gform-field-label--type-inline'>Therapist from the LGBTQ+ community<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_49_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.5' type='checkbox'  value='Older therapist (45+)'  id='choice_6_49_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_5' id='label_6_49_5' class='gform-field-label gform-field-label--type-inline'>Older therapist (45+)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_49_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.6' type='checkbox'  value='Non-religious therapist'  id='choice_6_49_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_6' id='label_6_49_6' class='gform-field-label gform-field-label--type-inline'>Non-religious therapist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_49_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.7' type='checkbox'  value='Therapist of color'  id='choice_6_49_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_7' id='label_6_49_7' class='gform-field-label gform-field-label--type-inline'>Therapist of color<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_50\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_50\"><legend class='gfield_label gform-field-label'  >Who referred you to Avadaroon?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_50'>\n\t\t\t<div class='gchoice gchoice_6_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Celebrity'  id='choice_6_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_50_0' id='label_6_50_0' class='gform-field-label gform-field-label--type-inline'>Celebrity<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Youtube'  id='choice_6_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_50_1' id='label_6_50_1' class='gform-field-label gform-field-label--type-inline'>Youtube<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Tiktok'  id='choice_6_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_50_2' id='label_6_50_2' class='gform-field-label gform-field-label--type-inline'>Tiktok<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='TV'  id='choice_6_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_50_3' id='label_6_50_3' class='gform-field-label gform-field-label--type-inline'>TV<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_50_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='gf_other_choice'  id='choice_6_50_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_50_4' id='label_6_50_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_6_50_other' class='gchoice_other_control' name='input_50_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_71' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"6\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"6\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_71' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"8\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"8\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_8' class='gform_page' data-js='page-field-id-71' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_8' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_6_53\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_53\"><label class='gfield_label gform-field-label' for='input_6_53' >Which country are you in?<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_6_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_6_54\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_54\"><label class='gfield_label gform-field-label' for='input_6_54' >What is your preferred language?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_6_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_6_55\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_55\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Please mark all that apply<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_55'><div class='gchoice gchoice_6_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='I&#039;m a student'  id='choice_6_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_55_1' id='label_6_55_1' class='gform-field-label gform-field-label--type-inline'>I'm a student<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='I&#039;m a veteran'  id='choice_6_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_55_2' id='label_6_55_2' class='gform-field-label gform-field-label--type-inline'>I'm a veteran<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='I&#039;m disabled'  id='choice_6_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_55_3' id='label_6_55_3' class='gform-field-label gform-field-label--type-inline'>I'm disabled<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='I&#039;m unemployed'  id='choice_6_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_55_4' id='label_6_55_4' class='gform-field-label gform-field-label--type-inline'>I'm unemployed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='I&#039;m employed but my income is low'  id='choice_6_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_55_5' id='label_6_55_5' class='gform-field-label gform-field-label--type-inline'>I'm employed but my income is low<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_55_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.6' type='checkbox'  value='I&#039;m financially impacted by the coronavirus outbreak'  id='choice_6_55_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_55_6' id='label_6_55_6' class='gform-field-label gform-field-label--type-inline'>I'm financially impacted by the coronavirus outbreak<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_72' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"7\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"7\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_72' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"9\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"9\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_9' class='gform_page' data-js='page-field-id-72' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_9' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_6_65\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_65\">Are there any issues you'd like to focus on? We want to match you with a therapist who suits your needs.<\/div><fieldset id=\"field_6_58\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_58\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Additional focus areas I prefer<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_58'><div class='gchoice gchoice_6_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Communication Problems'  id='choice_6_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_1' id='label_6_58_1' class='gform-field-label gform-field-label--type-inline'>Communication Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Life Purpose'  id='choice_6_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_2' id='label_6_58_2' class='gform-field-label gform-field-label--type-inline'>Life Purpose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.3' type='checkbox'  value='Isolation\/Loneliness'  id='choice_6_58_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_3' id='label_6_58_3' class='gform-field-label gform-field-label--type-inline'>Isolation\/Loneliness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.4' type='checkbox'  value='Self-Love'  id='choice_6_58_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_4' id='label_6_58_4' class='gform-field-label gform-field-label--type-inline'>Self-Love<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.5' type='checkbox'  value='Social Anxiety and Phobia'  id='choice_6_58_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_5' id='label_6_58_5' class='gform-field-label gform-field-label--type-inline'>Social Anxiety and Phobia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.6' type='checkbox'  value='Guilt and Shame'  id='choice_6_58_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_6' id='label_6_58_6' class='gform-field-label gform-field-label--type-inline'>Guilt and Shame<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.7' type='checkbox'  value='Post-traumatic Stress'  id='choice_6_58_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_7' id='label_6_58_7' class='gform-field-label gform-field-label--type-inline'>Post-traumatic Stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.8' type='checkbox'  value='Panic Disorder and Panic Attacks'  id='choice_6_58_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_8' id='label_6_58_8' class='gform-field-label gform-field-label--type-inline'>Panic Disorder and Panic Attacks<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.9' type='checkbox'  value='Control Issues'  id='choice_6_58_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_9' id='label_6_58_9' class='gform-field-label gform-field-label--type-inline'>Control Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.11' type='checkbox'  value='Forgiveness'  id='choice_6_58_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_11' id='label_6_58_11' class='gform-field-label gform-field-label--type-inline'>Forgiveness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.12' type='checkbox'  value='Caregiver Issues and Stress'  id='choice_6_58_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_12' id='label_6_58_12' class='gform-field-label gform-field-label--type-inline'>Caregiver Issues and Stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.13' type='checkbox'  value='Pregnancy and Childbirth'  id='choice_6_58_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_13' id='label_6_58_13' class='gform-field-label gform-field-label--type-inline'>Pregnancy and Childbirth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.14' type='checkbox'  value='Divorce and Separation'  id='choice_6_58_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_14' id='label_6_58_14' class='gform-field-label gform-field-label--type-inline'>Divorce and Separation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.15' type='checkbox'  value='Attachment Issues'  id='choice_6_58_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_15' id='label_6_58_15' class='gform-field-label gform-field-label--type-inline'>Attachment Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.16' type='checkbox'  value='Abandonment'  id='choice_6_58_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_16' id='label_6_58_16' class='gform-field-label gform-field-label--type-inline'>Abandonment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.17' type='checkbox'  value='Body Image'  id='choice_6_58_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_17' id='label_6_58_17' class='gform-field-label gform-field-label--type-inline'>Body Image<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.18' type='checkbox'  value='Mood Disorders'  id='choice_6_58_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_18' id='label_6_58_18' class='gform-field-label gform-field-label--type-inline'>Mood Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.19' type='checkbox'  value='Impulsivity'  id='choice_6_58_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_19' id='label_6_58_19' class='gform-field-label gform-field-label--type-inline'>Impulsivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.21' type='checkbox'  value='Workplace Issues'  id='choice_6_58_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_21' id='label_6_58_21' class='gform-field-label gform-field-label--type-inline'>Workplace Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.22' type='checkbox'  value='Money and Financial Issues'  id='choice_6_58_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_22' id='label_6_58_22' class='gform-field-label gform-field-label--type-inline'>Money and Financial Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.23' type='checkbox'  value='Chronic Pain Illness and Disability'  id='choice_6_58_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_23' id='label_6_58_23' class='gform-field-label gform-field-label--type-inline'>Chronic Pain Illness and Disability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.24' type='checkbox'  value='Women&#039;s Issues'  id='choice_6_58_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_24' id='label_6_58_24' class='gform-field-label gform-field-label--type-inline'>Women's Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.25' type='checkbox'  value='Men&#039;s Issues'  id='choice_6_58_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_25' id='label_6_58_25' class='gform-field-label gform-field-label--type-inline'>Men's Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.26' type='checkbox'  value='Sexuality'  id='choice_6_58_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_26' id='label_6_58_26' class='gform-field-label gform-field-label--type-inline'>Sexuality<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.27' type='checkbox'  value='Midlife Crisis'  id='choice_6_58_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_27' id='label_6_58_27' class='gform-field-label gform-field-label--type-inline'>Midlife Crisis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_58_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.28' type='checkbox'  value='Narcissism'  id='choice_6_58_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_28' id='label_6_58_28' class='gform-field-label gform-field-label--type-inline'>Narcissism<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_57\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_57\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >I prefer a therapist with experience in...<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_57'><div class='gchoice gchoice_6_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Depression'  id='choice_6_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_1' id='label_6_57_1' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Stress and anxiety'  id='choice_6_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_2' id='label_6_57_2' class='gform-field-label gform-field-label--type-inline'>Stress and anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Coping with addictions'  id='choice_6_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_3' id='label_6_57_3' class='gform-field-label gform-field-label--type-inline'>Coping with addictions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='LGBT-related issues'  id='choice_6_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_4' id='label_6_57_4' class='gform-field-label gform-field-label--type-inline'>LGBT-related issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Relationship issues'  id='choice_6_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_5' id='label_6_57_5' class='gform-field-label gform-field-label--type-inline'>Relationship issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.6' type='checkbox'  value='Family conflicts'  id='choice_6_57_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_6' id='label_6_57_6' class='gform-field-label gform-field-label--type-inline'>Family conflicts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.7' type='checkbox'  value='Trauma and abuse'  id='choice_6_57_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_7' id='label_6_57_7' class='gform-field-label gform-field-label--type-inline'>Trauma and abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.8' type='checkbox'  value='Coping with grief and loss'  id='choice_6_57_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_8' id='label_6_57_8' class='gform-field-label gform-field-label--type-inline'>Coping with grief and loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.9' type='checkbox'  value='Intimacy related issues'  id='choice_6_57_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_9' id='label_6_57_9' class='gform-field-label gform-field-label--type-inline'>Intimacy related issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.11' type='checkbox'  value='Eating disorders'  id='choice_6_57_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_11' id='label_6_57_11' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.12' type='checkbox'  value='Sleeping disorders'  id='choice_6_57_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_12' id='label_6_57_12' class='gform-field-label gform-field-label--type-inline'>Sleeping disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.13' type='checkbox'  value='Parenting issues'  id='choice_6_57_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_13' id='label_6_57_13' class='gform-field-label gform-field-label--type-inline'>Parenting issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.14' type='checkbox'  value='Motivation, self esteem, and confidence'  id='choice_6_57_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_14' id='label_6_57_14' class='gform-field-label gform-field-label--type-inline'>Motivation, self esteem, and confidence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_57_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.15' type='checkbox'  value='Anger management'  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